Monkeypox: new clinical features and presentations

Monkeypox: new clinical features and presentations

In May 2022, the UK High Consequence Infectious Diseases (HCID) issued an alert regarding an individual who had returned from West Africa infected with monkeypox, a viral disease caused by orthopoxvirus. Over the course of the week, six more autochthonous cases were reported and, by mid-July, 1735 cases had already been identified. Patients in several other countries have also been reported since then.

The clinical features seen in the 2022 monkeypox outbreak differ from those in historical reports. A recent English study describes a case series with new presentations of the disease that were followed up at a center in South London from 13 May to 1 July 2022.

Read too: Monkeypox: Anvisa releases the use of medicines and vaccines approved by international authorities

What did we know about Monkeypox until then?

The incubation period is around 12 days (5-24 days). The description of the classic symptoms was of a biphasic clinical course, with a prodromal phase characterized by fever, prostration, chills, adenopathy, headache, followed by rashes around two to four days later.

The skin lesions followed a typical pattern of evolution: they started as macules and progressed to papules, vesicles, pustules, which form crusts and flake off. Historically, the lesions appear and progress simultaneously, which serves to differentiate it from other viral diseases such as chickenpox. Lesions are predominantly concentrated on the face (95%), palms of the hands and soles of the feet (75%), mucous membranes (70%), and more rarely in the genital region.

Most infections were self-limiting, with mild to moderate involvement and symptoms lasting 2-4 weeks. Severe manifestations included encephalitis, secondary infection of the skin lesions, pneumonia, and eye involvement that could lead to blindness. At-risk populations were concentrated in neonates, children, and immunocompromised individuals. However, the characteristics of the current outbreak differ from the classic presentation, as described in the following study.

The current outbreak of Monkeypox

In the study in question, 197 patients were followed, all men, with a mean age of 38 years. All had the Monkeypox diagnosis confirmed by PCR. Of these, 196 participants identified themselves as MSM (men who have sex with men). Most participants had mucosal lesions, 56.3% in the genital region and 41.6% in the perianal region. The predilection for these areas, added to the history of 96% of the patients reporting recent sexual contact, suggests that the lesions start at the inoculation site, followed by systemic symptoms and, then, dissemination of the lesions.

Of those analyzed, 35.5% had cutaneous manifestations at different stages of evolution, which may suggest autoinoculation. In the initial care, 47.2% of the patients had only mucocutaneous manifestations or developed systemic symptoms after the appearance of the lesions. Another 11.2% had a single skin lesion, a manifestation that can be confused with syphilis, granuloma venereum or folliculitis. Seventy-one participants (36%) had pain in the rectum or pain to defecate and, of these, eight were hospitalized, five had confirmed proctitis and one had rectal perforation. Of these cases, 35.9% had concomitant HIV infection.

In addition to these manifestations, 31 participants (15.7%) had penile edema and, of these, five had paraphimosis; 13.7% had oropharyngeal lesions and 4.6% had erythema, pustule, edema or abscess. In addition, 31.5% had a concurrently sexually transmitted infection (STI), with N. gonorrhoeae and C. trachomatis, in rectal swab samples, the most common, which may explain the intensity of rectal symptoms.

Only a quarter of the monkeypox positive patients had contact with someone known to be sick, which raises the possibility of transmission by asymptomatic and oligosymptomatic individuals. Of the patients who tested negative for Monkeypox, the most common diagnoses were: syphilis, herpes simplex, herpes zoster, No gonorrhoeae and C trachomatis. The infection is usually self-limiting, with low lethality. In the study, no deaths were reported and the hospitalized patients only needed symptom control (mainly rectal pain and penile swelling).

What do we still not know?

We need more research to understand the transmission model, particularly with regard to sexual contact and spread by asymptomatic individuals. The increase in the number of affected patients favors the disease reaching vulnerable populations and the implications of this are still unclear.

In addition, nosocomial transmission, although infrequent, can happen with an undiagnosed atypical case, which can put other patients and the health team at risk.

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